06 January 2007

Clinical Pre-op diagnosis : Acute right lower quadrant pain.Post-op diagnosis : None given.Specimen : Appendix.Macroscopic The specimen is submitted in a formalin-filled container having a label with the patient's printed identification data, including her name "xxxxx, xxxxx". The label also has the penned inscription "appendix" and the container holds a 9 cm-long vermiform appendix with a very small amount of attached adipose tissue. The appendix ranges from 0.8 cm to 1.1 cm in diameter and generally has an erythematous serosa. The proximal end of the appendix is closed by surgical staples. The serosa of the middle to the appendix contains a sizeable plaque of yellow-tan, fibrinous exudate. The appendiceal lumen ranges from 0.1 cm to 0.4 cm in diameter and is filled with a mixture of red, viscous exudate and fecal material. Beneath the zone of serosal exudate, the appendiceal mucosa, submucosa, and wall exhibits much red discoloration. However, no perforation is evident. The remainder of the appendix exhibits focal red discoloration. One longitudinal section of the appendiceal tip and two representative cross-sections are submitted for histologic processing in one cassette.Final Diagnosis: ACUTE APPENDICITIS.---------------------------------------------

Remember what I said about 90% of the diagnostics in EM being reflex? This one wasn't. It was a 13 year old girl with nausea and vomiting, high fevers, and a bit of diarrhea. She had some vague cramping pain which was epigastric. We've seen tons and tons of gastroenteritis recently and this seemed like more of the same. She looked a bit dry, so I started an IV for hydration and got some labs. Her WBC was elevated at 18,000, which is quite high. Initially, I wrote this off as being due to dehydration, which can make the WBC count go up. It's actually a little too high for appendicitis, classically. She seemed pretty uncomfortable, though, so I decided to play it safe and image her abdomen. I got an ultrasound since she was skinny as a rail (better to avoid the radiation of a CT scan, as well), and to my surprise it showed a "tubular noncompressible structure in the RLQ suggestive of possible appendicitis."

The language the radiologist used was not really definitive, so I went back and re-examined the patient (no, really!), and she did now have some discrete tenderness in the right lower quadrant which she had not had before, though there was no guarding or rebound tenderness. So with an evolving exam and suggestive ultrasound, it was time to call a surgical consult. To be frank, I did have some misgivings about the diagnosis, as it was not exactly a classic presentation, and I rather doubted she would go to the OR. The conversation went like this:

Me: Hi, Dr Grim, I've got a young girl with a fever, evolving RLQ pain, elevated WBC, and an ultrasound suggesting appendicitis.Dr Grim: (cheerful, but distracted) Sounds like she needs an operation. Send her up.Me: OK, but I should let you know her presentation is more like a little GE, and . . .Dr Grim: (still cheerful) Yeah, that's great. Go ahead and send her.Me: Sure, but the ultrasound was not quite. . .Dr Grim: (a little less cheerful) Sure, sure. That's fine. Send her up.Me: Okaaaay.

So up she went, and I felt a little guilty that she didn't really have an iron-clad diagnosis, and a little worried that the surgeon hadn't wanted to hear about all the data. Was he going to be pissed when he met her and her exam wasn't great? Would he send her home? Or would he take her to the OR without even examining her? I was going to feel pretty bad if she had a negative laparotomy. Oh well, I did try, and Dr Grim is the one who is going to bear responsibility. . . right?

So I was pretty pleased to get the above-noted path report in my box today. Score one for the home team.

Sounds kind of like how my appendicitis went. In the end, they decided to operate because "bad things always happen to the kids of ER docs." The appendix ruptured as the surgeon was taking it out, apparently.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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